ISSUEBRIEF

Defining Rural Population Health and Health Equity

OverviewAs the terms “population health” and “health equity” become integrated into the rural

health vocabulary, it is important to establish a unified understanding of what these terms

mean. This issue brief aims to define population health and health equity, with particular

attention to the nuances for rural clinical partners. It can be used to educate rural health

and clinical care partners on their approaches to population health and health equity and

engage rural health stakeholders in meaningful discussions that improve the health and

well-being of rural residents.

This brief has been developed by the National Organization of State Offices of Rural Health (NOSORH) with support from the Federal Office of Rural Health Policy (FORHP)*.

Defining Population Health and Health EquityPopulation Health — at a broad level, population

health is defined as the health outcomes of a

group of individuals, including the distribution of

such outcomes in the group. The phrase “group of

individuals” could apply to a geographic location

or other groups stratified by their demographic

characteristics, such as gender, race or ethnicity.

Functional definitions of population health are

applied to identified groups of interest, which may be

a service catchment area for an organization

or a targeted subpopulation of need.

For rural hospitals, population health often focuses on

Internal Revenue Service (IRS) community-benefit

requirements, outcomes-based quality improvement

efforts, and reimbursable services (access to primary

care, availability of maternal health services, care

coordination,

etc.). These

valuable efforts

should be

undertaken

concurrently

with local

public health

and other

community

partners to simultaneously address social and

environmental factors impacting health outcomes

of the population.

Health Equity — A distinct difference exists

between equality and equity — where equality

provides everyone with the same opportunity and

equity levels the playing field to provide everyone

with the same opportunity. Though a commonly

used term, the definition of health lacks consensus.

VOLUME 2 | ISSUE 5 l JULY 2020

N A T I O N A L O R G A N I Z A T I O N O F S T A T E O F F I C E S O F R U R A L H E A L T H

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Common Elementsn recognizes a group of

individuals sharing one or more attributes

n incorporates regular analysis of data to identify trends and needs.

The World

Health

Organization

recognizes

health equity

as the absence

of avoidable,

unfair or

remediable

differences

among groups

of people,

whether those are defined socially, economically,

demographically, geographically or by other means

of stratification. Health equity implies that everyone

should have a fair opportunity to attain their full

health potential, and no one should be disadvantaged

from achieving this potential.

The Robert Wood Johnson Foundation offers a

functional definition of health equity as “[having] a

fair and just opportunity to be as healthy as possible.

This requires removing obstacles to health such as

poverty, discrimination, and their consequences,

including powerlessness and lack of access to good

jobs with fair pay, quality education and housing, safe

environments, and health care.”

Population health in rural and frontier communitiesPopulation health efforts come in a variety of forms,

depending upon the audience. For instance, a

hospital may focus on accessibility to primary care as

a sustainable contribution toward broader population

health efforts. However, there are many other efforts

rural health stakeholders may be in a position to

undertake.

n Through the Hawaii Smiles program, all 3rd

graders are provided with a free, non-invasive

dental screening during the school day. Children

who are in need of dental care are referred to their

dentist or a local clinic for follow up. This program

ensures basic access to preventative oral health

services, while removing barriers to transportation,

affordability, and truancy.

n The HEALing Seeds program connects residents of

several rural communities in Allen County, Indiana,

to training and education that encourages healthy

cooking and increased access to healthy foods.

Addressing what people eat, and how making

changes can have a significant impact on an

individual’s health outcomes. The goal of HEALing

Seeds is to improve the health outcomes of the

population of their communities.

n The South Carolina Rural Health Action Plan is

a comprehensive, statewide plan for addressing

the health and well-being of rural South

Carolinians over a 3-5 year period. The key to

this project was the collaboration with local

community stakeholders and engaging partners

outside of the traditional health sector. Partners

worked to develop strategies that addressed

the unmet health and social needs of residents.

The final report included five areas of focus, 15

recommendations, and over 50 action steps in the

areas of physical activity, transportation, housing

and more.

n Louisiana has gone beyond the collaborative

spirit to integrating with its Chronic Disease

Management and Health Promotion teams,

creating a new Well-Ahead LA division. The joint

division works to ensure rural community needs

are addressed while expanding Centers for Disease

Control and Prevention (CDC) programs that may

disproportionately benefit urban communities

otherwise.

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Common Elementsn recognizes the population

(i.e., demographic, geographic, etc.) and the individual

n incorporates the barriers (social, economic, racial, etc.) to achieving optimal health.

Just as with the definitions of health equity, there

are a variety of ways in which rural and frontier

stakeholders are addressing inequities in their

communities.

n Alaska’s Community Cafes are an opportunity

for residents to address underlying community

issues, whether related to a health concern or some

other topic. Cafes last an hour, with the first 25

minutes devoted to a presentation on a given topic.

Participants are then divided into smaller groups

for discussion.

n Having a connection to what matters is really what

can make good, positive change in the community.

Hawaii’s Rural THRIVE is a long-term strategy to

improve the health and well-being of vulnerable

populations and communities. As part of the initial

phase, 17 community forums were held on all six

islands, including discussions and storytelling

sessions from local community members.

n Arizona SHARES gives healthcare students a

better understanding of social support services and

how to connect individuals with those services —

particularly health insurance coverage. By serving

as something similar to a Community Health

Worker, students earn volunteer credits, allowing

them to graduate with distinction. Graduates of the

program are better equipped to answer patients’

questions about coverage on the spot.

n Montana Healthy Communities began as small

seed grants for equitably transforming local rural

communities. Seed grants helped to support a

range of projects including a farmer’s market, a

community garden, and chemo care kits. Though

funding has completed, the project still maintains

a platform for sharing innovations and lessons

learned with other rural communities. The website

showcases local wellness initiatives, provides

evidence-based program ideas, and offers monthly

health and wellness webinars. In addition, it

publishes a weekly online newsletter.

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Health equity in rural and frontier communities

Rural health partners should recognize that achieving

health equity and addressing the needs of rural

populations requires systematic, community-wide

change. Key rural health organizations should be

prepared to lead and/or support these efforts,

acknowledging the long-term goal of achieving health

equity. Rural clinical partners can have a positive

impact on population health and health equity by:

n Organizing or participating in cross-sector

discussions between health and human service

organizations and community partners to identify

common challenges and opportunities for

collaboration. Consider leveraging a HRSA Rural

Community Programs grant to fund these efforts.

n Creating an organizational culture that routinely

examines health indicators and community

data to address clinical and upstream patient

needs. Consider developing a Community

Health Improvement Plan (CHIP) from available

community health needs assessment (CHNA)

data. Find more information on conducting rural

CHNAs and CHIPs here.

n Adopting policies and strategies to improve

accessibility and availability of primary care

or specialty services (i.e. extended hours,

childcare services, telemedicine, etc.) based

on patient barriers.

n Leverage students and other academic partners

in outreach efforts. This not only trains the next

generation of public health and healthcare leaders

concurrently, it integrates population health and

health equity into the learned experiences of

the students.

n Ensuring an inclusive environment for all patients

by: recruiting leadership and providers that are

representative of the patient populations, adding

larger waiting room seats, offering a quiet waiting

area option, requiring cultural competency training

for all staff, ordering larger patient gowns, having

language interpreters readily available, and

implementing a screening and referral system for

social determinants of health.

ConclusionAs shifts in the evolving rural health landscape focus

more attention on the non-clinical factors impacting

health outcomes, rural health stakeholders should

recognize the variations in approaches and priorities

for community partners. By understanding how these

approaches differ, conversations can begin to move

communities toward improved health outcomes and

health equity for rural populations.

NOSORH ISSUE BRIEF | 44648 Mound Road, #114 | Sterling Heights, MI 48314-1322 | (888) 391-7258 | www.nosorh.org

Additional Rural Population Health Resources

TASC Population Health Toolkit

RHIhub: Population Health

RHIhub: Rural Health Disparities

* Disclaimer: This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Cooperative Agreement #U14RH19776 State Offices of Rural Health Coordination and Development Program (SORHCDP) $750,000.

This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government

NOSORH is dedicated to building the capacity of State Offices of Rural Health and their

stake holders to grow leadership for population health and health equity. For more

information contact Chris Salyers, DHSc Education and Services Director.

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